Case

A 47-year-old patient reports painless difficulty swallowing, particularly with liquids where they report frequent aspiration of the liquid to their airways.  The patient also reports a long history of slight swallowing difficulty which has gotten progressively worse over the last months.

Question 1/2 - What possibilities should be on your differential diagnosis?

Click on your selected option(s) below  (correct = 3, possible = 4, over-thinking = 5+)

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Correct!  A mass effect (e.g. a tumor) in the pharynx could progressively be restricting the passage of food resulting in the dysphagia.

Incorrect. Bell's palsy is a sudden onsite facial nerve (CN VII) dysfunction. This is not consistent with the progressive slow onset reported by the patient.

Additionally, the facial nerve innervates the muscles of facial expression which are not involved in the swallow reflex. Patients with facial paralysis can have difficulty holding liquid in their mouth (due to lip paralysis), but can swallow normally.

Correct! A mass effect (e.g. a stricture narrowing the pharynx/esophagus) could progressively be restricting the passage of food resulting in the dysphagia.

Correct! Most of the muscles involved in swallowing are innervated by the vagus nerve (vagus is the primary motor side of the swallowing function). Dysfunction of this nerve could disrupt the muscular control of swallowing and cause dysphagia.

Possible. The hypoglossal nerve innervates the tongue musculature, not the pharyngeal musculature primarily responsible for the swallow reflex.

However, a patient with hypoglossal nerve dysfunction has difficulty swallowing in normal posture due to the role the tongue plays in moving food to the posterior oral cavity and into the pharynx. Patients need to tilt their head back to gain a gravity positioning assist, then the pharyngeal muscle sequence can take over the remainder of the swallow motion.

Incorrect. While tonsillitis can result in a mass effect through enlarged parietal tonsils impeding swallowing, inflammatory reactions are painful and not consistent with the reported painless dysfunction.

Incorrect. The trigeminal nerve provides sensation from the face and controls the muscles of mastication. Palsy would result in difficulty chewing, but the trigeminal nerve does not innervate the tongue or pharynx so a patient with trigeminal palsy would be able to swallow.

Correct! The glossopharyngeal nerve is primarily a sensory nerve to the pharynx (though also innervates one pharyngeal muscle). Disruption of this nerve would impede the sensory side of the swallowing mechanisms...to swallow properly there needs to be a sequence of sensorimotor functions where disruption to either sensory or motor can cause dysphagia.